BUECHEL MEMORIAL LAKOTA MUSEUM 350 South Oak Street P.O. Box 499 St. Francis, SD 57572 PERMISSION FORM FOR USE OF PHOTOGRAPHS The undersigned requests permission to borrow prints of photographic images from the Buechel Memorial Lakota Museumâ€™s Photograph Collection Archives. In providing these images it is understood by the party/parties here to that these images are released for a one-time use in the publications. Name of Company:________________________________________________ Address:_________________________________________________________ Telephone:________________________Date___________________________ State use of publication:__________________________________________________
State desired photograph or photograph ID Number(s) to use:
Author or Publisher:______________________________________________________ FORM OF CREDIT TO ACCOMPANY PUBLISHED PRINTS: BUECHEL MEMORIAL LAKOTA MUSEUM PHOTO ARCHIVES ST. FRANCIS MISSION ST. FRANCIS, SD 57572 In providing the prints, it is understood that the above Institution, Firm or Individual, will not otherwise copy or permit the use of any portion of the photographs herein listed, in any publication, motion picture, television production or any kind of reproduction or sale without the specific written authorization of the Buechel Memorial Lakota Museum.